General Informed Consent and Agreement
About me: As a 3rd generation Washingtonian born in the Puget Sound area, my sense of connection here runs
deep. So does my commitment to serving people in this community. I bring 15 years' experience working with
people from diverse cultural, spiritual and economic backgrounds including youth, adults, students, couples,
families and veterans. My area of particular expertise is in Trauma-Informed Psychotherapy.
I am a Licensed Independent Clinical Social Worker; my Washington State Department of Health license
number is LW 60165078. My work is holistic and grounded in several core values: the importance of
relationships, unconditional positive regard, integrity, dignity and worth of the person, clinical competence and
service. I work with individuals, families, couples and groups.
Therapeutic approaches on which I rely include Cognitive Behavioral, Psychodynamic, Motivational
Enhancement, Gestalt, Narrative Therapy, Brief Solution Focused, Family Systems, Group Therapy and
PsychoEducation. I continually re-assess my work through the lens of cultural relevancy and social justice,
values that I cherish. Trust and a strong sense of emotional, psychological, physical and spiritual safety are
essential to supporting your goals for therapy, healing, and wholeness.
My training includes formal education and over 15 years of experience in the field, a Master’s Degree in Social
Work from the University of Washington (1999), and many hours of continuing education in the following
subjects (among others): Trauma, PTSD and Traumatic Grief; Working with Survivors of Sexual Abuse; A
Soldier's Heart: From Combat to College; Culturally Competent Practices; Motivational Interviewing For
Substance Abuse and Mental Health Clinicians, Relationships and Neuroplasticity in Psychotherapy, and Relapse
Prevention. I am committed to maintaining ethical and best practices through continuing education,
consultation and specialized training. Currently, I am enrolled in a year-long training to add Sensorimotor
Psychotherapy to my practice repertoire.
Our work together: I believe you are the expert on your experience and concerns, and that healing is within
your reach. Many solutions exist in your own insights, self-discovery, strengths and resiliency. My role is to
serve as a skillful, respectful, compassionate therapist and collaborator, honored to accompany you on your
journey toward personal goal achievement, self-realization, healing, and wholeness. You have the right to ask
questions and have input regarding our work together, as well as the right to refuse treatment. It is important
to me that you choose the professional and treatment approaches that best suit your needs; I am happy to
refer you to other professionals if this is not the best “match”.
Counseling concerns faced by folks with whom I work include recovery from physical or psychological trauma,
dramatic or unexpected life change (i.e. job separation), exploration of personal and/or professional identity,
depression, anxiety, loss (including death of a loved one), complex grief, mental health, substance abuse and
dual diagnosis.
Confidentiality: All information you share with me is confidential unless a release of information is received
with your signature authorizing disclosure to a specified person or agency as per your request. However,
Washington State law requires that confidential information be released under the following circumstances for
the purpose of securing the safety of the client or others:
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Informed Consent & Agreement – P2
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If there is reason to suspect that a child or dependent adult is being abused or neglected or has been within
the past several years.
If a client is considered an imminent danger to him/herself or to someone else and/or is grossly unable to
take care of his/her basic life-sustaining needs.
Under court order, specific information may have to be disclosed.
Basic information about diagnosis and treatment in order to obtain insurance coverage.
Please refer to my Privacy Practices information sheet for more details about the limits of confidentiality.
In the event you cease therapy and 3-6 months have transpired since our last appointment or communication,
with no appointments scheduled in the future, I am obligated by ethical guidelines of the profession to
close your file and discharge you as a client. I will also notify you of such action in writing.
If you have a concern about the quality of care you receive, please feel free to discuss this directly with me. You
may file a complaint against any licensed social worker and access a description of unprofessional conduct from
the Department of Health website at: http://www.doh.wa.gov/hsqa/Complaint.htm
I authorize Cynthia Shaw, MSW LICSW to release necessary information in discerning the status of insurance
claims to any third party payer.
I have read and understand this General Informed Consent and Agreement. I have been given the Notice of
Privacy Practices. I agree to participate in treatment with Cynthia Shaw MSW LICSW.
I understand that the fee for my initial private pay appointments are $150-175.00 per/hour, and the fee for
subsequent insurance approved visits is $130-$150.00 per/hour. Initial appointments are billed at $150-$175.00
per hour. I understand that these fees are ultimately my responsibility to pay in full.
I understand that same-day cancellations or no-shows will be billed to me at half the full hourly rate.
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Signature of Client(s)
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Date
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Cynthia Shaw, MSW, LICSW
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Date
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